Wednesday, September 14, 2011

In 1849, Rudolf Ludwig Karl Virchow, noted the involvement of remote lymph nodes in intraabdominal cancers. 40 years later, Troisier, reporting several cases of intra-abdominal malignancy where supraclavicular lymph nodes were the only external indication of cancer, coined the term Virchow's node to describe this finding. In current usage, Virchow's node refers to a left supraclavicular lymph node that is the harbinger of an abdominal malignancy. It should be remembered that inflammatory and infectious abdominal processes can also lead an enlarged left supraclavicular lymph nodes.

The thoracic duct drainage has been implicated for the involvement of left supraclavicular lymph nodes. The thoracic duct drains the left jugular, left subclavian, and left mediastinal lymph nodes superiorly. Inferiorly, the thoracic duct drains the intercostal lymphatics, and via the cisterna chyli, the lower intercostal, gastric, superior mesenteric, inferior mesenteric, lumbar, and internal and external iliac lymphatics.

The left supraclavicular lymph nodes drain into the thoracic duct via short lymphatic channels draining into the left jugular lymphatics. Reflux into the left supraclavicular lymph nodes from the thoracic duct is relatively easy, occurs in half of patients with unobstructed lymphatic drainage, and is the proposed etiology of Virchow's node.

The right-sided lymphatic drainage, on the other hand, is not from the abdomen, being predominantly from the right subclavian, right mediastinal, and right jugular vessels.

The case above is from a patient with endometrial carcinoma who had metastases to bilateral supraclavicular lymph nodes. Retroperitoneal adenopathy can also be seen. Biopsy of a left supraclavicular lymph node yielded cells similar to the patient's primary malignancy.